Medicines Error And Safety Flashcards
Define medication error
A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health professionals, patient or consumer.
Define medication safety
medication safety : freedom from accidental injury during the course of medication use; activities to avoid, prevent, or correct adverse drug events which may result from the use of medications.
Put these in order - dispensing, administering , monitoring , help seeking , prescribing
Prescribing, dispensing , administering , monitoring , help seeking
Why do we study medication error/ safety (3)
1) adverse drug events
2) adherence problems
3) medication errors
What strategies have been used to reduce medication errors (5)
1) computerised physician ordering entry systems with clinical decision support systems
2) utilisation of clinical pharmacists
3) double checking of medication orders
4) incident reporting
5) education and training
Explain the persons approach to errors
Persons: focuses on the unsafe acts—errors and procedural violations—of people at the sharp end. It views these unsafe acts as arising primarily from aberrant mental processes such as forgetfulness, inattention, poor motivation.the associated countermeasures are directed mainly at reducing unwanted variability in human behaviour. - to learn from errors and near misses - establish nationwide solutions - prevent further errors
Explain the systems approach to errors
Systems approach:
The basic premise in the system approach is that humans are fallible and errors are to be expected, even in the best organisations. Countermeasures are based on the assumption that though we cannot change the human condition, we can change the con- ditions under which humans work. When an adverse event occurs, the important issue is not who blundered, but how and why the defences failed.
Explain why error reporting is important (3)
1) understand how errors or hazards have arisen
2) be able to address them at a systems level
3) no one would know about errors or hazards
Provide some examples of changes to working practices that have been implemented to reduce errors (4)
1) changes to medication packaging to avoid mix ups
2) changing connectors for intrathecal injections
3) introducing tabards for drug rounds
4) introducing greater controls on monitoring warfarin
List where you can report adverse drug reactions (4)
1) MHRA - yellow card scheme
2) natural reporting and learning system
3) healthcare staff
4) near miss log
What is a human factors approach
Human factors encompass all those factors that can influence people and their behaviour . In a work context, human factors are the environmental, organisational and job factors, and individual characteristics which influence behaviour at work.
Outline why a person might not report an error (6)
1) not recognising hazards and safety incidents
2) too busy
3) fear of blame
4) cumbersome reporting system
5) no feedback in outcomes of reports
6) no evidence of learning from reports
Systems approach from a human factors perspective - what can you do? (4)
1) understand where you work
2) understand the task at hand- what and how
3) understand what others do - people and technology
4) understand your own skills and knowledge
